NEW PATIENT REGISTRATION FORM

Transcription

1 NEW PATIENT REGISTRATION FORM Patient (Legal) Name: Nickname: SSN (> Age 18): Date o f Birth: Sex: Male Female M ailing Hom e Address: Street/PO Box Address: Street City State Zip Code City State Zip Code The Federal government now requires that we collect the following information: Race: White Black/African American Hispanic/Latino Asian Multi-racial Other: Ethnicity: Hispanic Non-Hispanic Marital Status: Single Married Widowed Divorced Student Status: Full-Time Part-Time N/A Home Phone (1): _ Cell (Day) Phone (2): Work ( Alt) Phone (3): (1) Primary Insurance Insurance Name: Policy Holder Name: IN CASE OF EMERGENCY PLEASE CONTACT: Name: _ Relationship: Phone #: Effective Date: Date of Birth: Policy Holder Relationship to Patient: Self Spouse Parent Policy Ho lder Sex: Male Female Policy ID #: Group #: (2) Secondary Insurance Insurance Name: Policy Holder Name: Effective Date: Date of Birth: Policy Holder Relationship to Patient: Self Spouse Parent Policy Ho lder Sex: Male Female Policy ID #: Group #: For Minor Children Only: Responsible Party is the parent who comple tes this form Resp onsible Party Name: Home Phone: SSN: Date of Birth: Cell Phone: Mother s Name: Daytime Phone: Father s Name: Daytime Phone: ASSIGNMENT OF BENEFITS: I verify that the information provided above is complete and correct. I request that payment of authorized insurance or Medicare benefits be made on my behalf to Cape Fear Orthopaedic Clinic, P.A. for any medical services or supplies furnished to me by that org anization. I understand that I am financially responsible to the organization for any charges not cover ed by my health care benefits. Patient/Legal Guardian Signature: Date: Cape Fear Orthopaedic Clinic September 2013

2 HIPAA CONSENT & ACKNOWLEDGMENT Patient Name: Date of Birth: NOTICE OF PRIVACY PRACTICES I have been given a copy of Cape Fear Orthopaedic Clinic, P.A. s Notice of Privacy Practices, version effective September 1, I consent to the uses and disclosures of my health information as outlined in the Notice. **Signature of Patient or Representative: Print Name: Date: RELEASE OF PHI TO FAMILY I consent to disclosure of the following protected health information about me to the following family member(s) or person(s) involved in my care or payment for my care: None Name: Relationship: Information to be released (check all that apply): All Medical Record Copies/Prescriptions Appointment(s) Billing Name: Relationship: Information to be released (check all that apply): All Medical Record Copies/Prescriptions Appointment(s) Billing My consent will remain in effect as long as I am a patient of Cape Fear Orthopaedic Clinic, P.A. unless and until I notify Cape Fear Orthopaedic Clinic, P.A. in writing of any changes. **Signature of Patient or Representative: Print Name: Date: FOR OFFICE USE ONLY If an acknowledgment of receipt of the Notice of Privacy Practices is not obtained from the patient or the patient s representative, please explain your efforts to obtain acknowledgment and the reason you could not obtain it: Cape Fear Orthopaedic Clinic September 2013

3 Patient Name: Date of Birth: **PLEASE READ AND INITIAL EACH SECTION SIGNATURE REQUIRED ON PAGE 2** FINANCIAL POLICY We would like to thank you for choosing Cape Fear Orthopedics as your medical provider. Because we are committed to providing you with the best possible care and service, we would like to make you aware of our financial policy. We require that you read and initial this document prior to receiving medical treatment. Co-payments, Deductibles, and Fees: Co-payments, deductibles and fees for services not covered by your insurance are due at the time service is rendered. We accept cash, checks, and most major credit cards. A $25.00 fee will be assessed to your account if a check is returned for non-sufficient funds. Insurance: You must present a current insurance card at each visit. If your insurance plan is not one we participate with, we will assist in filing your insurance claim, but payment in full is expected at the time of service. It is your responsibility to provide timely and accurate information to our office so claims can be properly submitted. Minors and Dependants: Our practice will bill the insurance for both parents (if applicable). The parent that accompanies the child to his or her first appointment will be considered financially responsible for payment, regardless of the subscriber (parent) listed on the child s insurance card. We do not get involved in child custody issues. Auto Insurance/Third Party Liability: Please notify our office immediately if your injury is a result of an auto accident or third party liability. While we do not general accept third party liability, there are exceptions if you have Medicare or Medicaid. You may be responsible for payment at the time of service if your treatment is related to third party liability. Missed Appointments: Repeatedly missing, rescheduling, or cancelling appointments may be grounds for dismissal from the practice. Prompt Payment: We expect that you will make every effort to pay your bill promptly. If you do not have medical insurance, have a financial hardship, or if you are unable to pay your bill in its entirety please contact our billing office prior to your appointment to discuss payment options. Chronic non-payment will be grounds for dismissal from the practice. We reserve the right to turn any account over to a collection agency if the account is not paid within 30 days. Patient Financial Responsibility: I acknowledge full financial responsibility for services rendered by Cape Fear Orthopaedic Clinic, P.A. I understand that I am financially responsible for prompt payment of any portion of the charges not covered by insurance, including deductibles and copays. I understand payment of co-pays and any prior balance I may owe is due at the time of service unless a payment agreement is on file. I hereby request that payment of insurance or Medicare benefits be made on my behalf to Cape Fear Orthopaedic Clinic, P.A. for any medical services or supplies furnished to me by that organization. CONSENT TO TREATMENT I am a new or current patient at Cape Fear Orthopaedic Clinic, P.A. By signing this form, I consent to be treated by the providers of this practice. My medical provider needs more medical facts about my health. I ask for and allow the medical providers and staff to give me the needed medical treatment and services recommended by my physician or physician assistant. I understand that treatment and services may include, but is not limited to the following: routine exams diagnostic tests casts/splints injections lab tests x-rays screening tests I understand that no promises have been made to me about the results of any treatment or services. CONSENT TO OBTAIN EXTERNAL PRESCRIPTION HISTORY By signing below I give permission, without limitation or exclusion, for Cape Fear Orthopaedic Clinic, P.A. and it s providers to view my external prescription history via Surescripts for purposes of my care and treatment. I understand that my medication history from multiple other medical providers, insurance companies, and pharmacy benefit managers may be viewable and that granting this permission will allow my providers to better coordinate my care and to maximize the effectiveness and safety of my treatment plan. I certify that I read and understand the scope of my consent and that I authorize access. 1

4 PRESCRIPTION REFILL and PAIN MEDICATION POLICY Prescription Refills: 1. Only one pharmacy may be used for filling prescriptions. You should notify us if you change pharmacies. 2. Because most physicians are only in clinic 2-3 days per week, prescription refills may take 3-5 business days to process. Please do not wait until you run out of medication to request a refill. 3. Take your medication exactly as instructed by your provider. Never change the dosage or frequency of your medication without instructions from your physician. Refill requests will not be approved if you run out early. 4. You may request a refill during our normal business hours. Requests for refills will not be accepted after hours. 5. You are responsible for keeping your prescriptions and medications safely in your care. Lost or stolen medications or prescriptions will not be replaced until it is time for your next refill. Exceptions may be made if you have a police report, but only at the discretion of your doctor. 6. You may be required to see your physician for a follow-up visit prior to obtaining a medication refill. Pain Medications: If you have a medical condition requiring pain control, your medical provider may recommend that you take a narcotic (pain-killer) drug. These drugs should lower or take away your pain. There are some important things you should know about narcotic (pain-killer) drugs before you agree to take them: Pain-killer drugs may have major side effects and risks. Medication should be taken only as directed. Narcotic use is under the control of many regulatory agencies. Doctors must follow local, state, and federal laws when prescribing these drugs. Risks and common problems include: 1. Addiction You could become mentally and physically dependent on them. Your doctors may order extra blood, urine, or hair testing and may refer you to an addiction specialist if there is a worry about addiction. 2. Side effects Include a feeling of sickness to your stomach, trouble having a bowel movement, sweating, and itchiness of the skin. You may also feel sleepy. 3. Pregnancy Do not get pregnant while you are taking pain-killers. These drugs could result in harm to your baby or loss of the pregnancy (miscarriage). 4. Alcohol or illegal drugs Do not use alcohol or illegal drugs while taking pain-killers. This mixture could cause death. 5. Heavy or dangerous machinery Do not use heavy or dangerous machinery, handle guns, or use other weapons while taking painkillers. 6. Driving Driving while on a pain-killer drug is not recommended. Pain-killers can change your driving skills. By signing below you agree that you have read this document and understand the clinic s policy regarding prescriptions and the rules for taking narcotic (pain-killer) drugs: 1. It is against the law to make any changes to a prescription after it is written. If you change a prescription, it will be reported to the police and no more drugs will be given to you. 2. Getting pain-killer drugs from more than one doctor at a time is not allowed. This is against the law and may be considered a felony. You have a duty to let other doctors know if you are taking narcotic (pain-killer) drugs. 3. From time-to-time, our staff may talk to the pharmacist or access the NC Controlled Substance Reporting System to check your full prescription profile. 4. Prescriptions should only be picked up by you. If you are unable to pick up your prescriptions, we will only release your prescription to authorized persons as listed on your HIPAA Consent Form. Our office does require that you show a photo ID when picking up prescriptions. 5. I agree to comply with random urine, blood, or breathe testing to document the proper use of pain medication, as well as confirming compliance. I understand that it is my responsibility to comply with the laws of the state while taking the prescribed medications. **Signature of Patient or Representative: **Signature of Witness: Date: Time: am/pm (Office Use Only) Person#: Cape Fear Orthopaedic Clinic January

5 MEDICAL HISTORY FORM Patient Legal Name: Date of Birth: Primary Care Physician: Referring Provider: **PLEASE LIST EACH INJURY/PROBLEM (Body Part) SEPARATELY** (1) Reason for today s visit: Rate your pain from 1-10 (10 = worst): Injury Date (if applicable): Injury Type: work sports home auto accident third party other If no injury, when did this problem begin? Please describe how the injury/problem began: Since this began, is your pain: better worse unchanged Describe Symptoms/Pain: intermittent occasional constant rare aching burning dull piercing sharp throbbing Symptoms Aggravated by: standing walking lifting squatting kneeling bending pushing other: Symptoms Relieved by: rest ice elevation OTC medicine injection physical therapy nothing other: Other Symptoms: bruising crepitus decreased mobility difficulty sleeping fever locking pain swelling joint stiffness tenderness limping muscle stiffness numbness popping tingling weakness (2) Reason for today s visit: Rate your pain from 1-10 (10 = worst): Injury Date (if applicable): Injury Type: work sports home auto accident third party other If no injury, when did this problem begin? Please describe how the injury/problem began: Since this began, is your pain: better worse unchanged Describe Symptoms/Pain: intermittent occasional constant rare aching burning dull piercing sharp throbbing Symptoms Aggravated by: standing walking lifting squatting kneeling bending pushing other: Symptoms Relieved by: rest ice elevation OTC medicine injection physical therapy nothing other: Other Symptoms: bruising crepitus decreased mobility difficulty sleeping fever locking pain swelling joint stiffness tenderness limping muscle stiffness numbness popping tingling weakness DRUG ALLERGIES: **Please list any medication that you are allergic to. Drug/Type of Reaction: I have NO KNOWN DRUG ALLERGIES I am allergic to LATEX MEDICATION LIST: **Please list all over the counter and prescription medications that you are currently taking (including vitamins and herbal supplements). Medication/Dosage/Frequency: I DO NOT currently take any medications including vitamins or herbal supplements Preferred Pharmacy: Phone:

6 **IF YOU HAVE ALREADY ENTERED YOUR MEDICAL HISTORY INFORMATION THROUGH THE PATIENT PORTAL IT IS NOT NECESSARY FOR YOU TO COMPLETE THIS SIDE OF THE FORM** Past Medical History: No Previous Medical Problems AIDS/HIV Congestive heart failure GERD Migraine headaches Renal disease Alcoholism COPD Gout Multiple sclerosis Rheumatoid arthritis Alzheimer s Coronary artery disease Hepatitis Myocardial infarction Scoliosis Anemia Crohn s disease Hyperlipidemia Obesity Seizure disorder Angina Degenerative joint disease Hypertension Osteoarthritis Sleep Apnea Arthritis Depression Inflammatory bowel disease Osteoporosis SLE Asthma Diabetes Juvenile rheumatoid arthritis Parkinson s disease Spinal stenosis Atrial fibrillation Drug abuse Kidney disease Peptic ulcer disease Spondyloarthopathy BPH DVT Liver disease Psoriasis Thyroid disease Cancer Fibromyalgia Lyme disease PVD Valvular disease CVA (stroke) Gallbladder disease Other: Past Surgical History: Please indicate the year you had surgery if applicable No Previous Surgeries ACL Surgery: Back surgery : Hernia repair: Rotator cuff repair: Angioplasty: CABG: Hip Arthroplasty: Small bowel resection: Angio w/stent: Cardiac valve replacement: Hip Replacement: Thyroidectomy: Appendectomy: Carpal tunnel release: Knee Replacement: Tonsillectomy: Arthroscopy ankle: Cataract extraction: Laminectomy: Other: Arthroscopy elbow: Cholecystectomy (Gallbladder): LASIK: Arthroscopy hip: Colectomy: Meniscus surgery: Gender Specific: Arthroscopy knee: Colostomy: Muscle biopsy: C-Section: Arthroscopy wrist: Discectomy: ORIF: Hysterectomy: Arthroscopy shoulder: Gastric bypass: Pacemaker: Mastectomy: Family History: Alcoholism Congestive heart failure Gout Osteoarthritis Alzheimer s disease COPD Heart disease Osteoporosis Anemia CVA (stroke) Hypertension Parkinson s disease Asthma Diabetes Kidney disease Renal disease Blood disease Drug abuse Liver disease Seizure disorder Cancer: Bone Muscle disease Thyroid disorder Cancer: Obesity Other: Social History: Language Spoken: English Spanish Other: Hand Dominance: right left ambidextrous Current Work Status: full-time part-time self employed unemployed disabled retired Employer Name: Occupation: Marital Status: single married divorced widowed life partner How many children do you have? Who do you live with? live alone spouse parents mother father other: Tobacco Use: Current Type: cigarettes cigar pipe chewing How much per day: # Years: Former Year Quit: Never Alcohol Use: No Yes: daily weekly socially rarely How Much? Illicit Drug Use: No Yes Formerly Age Started: Years Drug Type: Frequency: Route: **Signature of Patient or Representative: Date: Verbal Information Patient Unable to Complete Form Staff Initials: Cape Fear Orthopaedic Clinic September 2013